Outcomes and cost of open versus endovascular repair of intact thoracoabdominal aortic aneurysm

Efficacy and Safety of Endovascular Fenestrated and Branched Grafts Versus Open Surgery in Thoracoabdominal Aortic Aneurysm Repair: An Updated Systematic Review, Meta-analysis, and Meta-regression

OBJECTIVE

To provide an updated systematic review and meta-analysis with meta-regression of efficacy and safety of fenestrated/branched endovascular repair of thoracoabdominal aortic aneurysms (TAAAs) compared with open repair.

BACKGROUND

Endovascular repair of TAAAs may be a promising alternative to open surgery by reducing invasiveness and expanding the eligible population, but evidence remains limited.

METHODS

We applied "Prepared Items for Systematic Reviews and Meta-analysis" guidelines to retrieve, quantitatively pool, and critically evaluate the efficacy and safety (including 30-day mortality, reintervention, spinal cord injury [SCI], and renal injury) of both approaches. Original studies were retrieved from PubMed, Embase, and Cochrane Library until April 20, 2022, excluding papers reporting <10 patients. Pooled proportions and means were determined using a random-effect model. Heterogeneity between studies was evaluated with I2 statistics.

RESULTS

Sixty-four studies met the predefined inclusion criteria. Endovascular cohort patients were older and had higher rates of comorbidities. Endovascular repair was associated with similar proportions of mortality (0.07, 95% confidence intervals [CI]: 0.06-0.08) compared with open repair (0.09, 95% CI: 0.08-0.12; P = 0.22), higher proportions of reintervention (0.19, 95% CI: 0.13-0.26 vs 0.06, 95% CI: 0.04-0.10; P < 0.01), similar proportions of transient SCI (0.07, 95% CI: 0.05-0.09 vs 0.06, 95% CI: 0.05-0.08; P = 0.28), lower proportions of permanent SCI (0.04, 95% CI: 0.03-0.05 vs 0.06, 95% CI: 0.05-0.07; P < 0.01), and renal injury (0.08, 95% CI: 0.06-0.10 vs 0.13, 95% CI: 0.09-0.17; P = 0.02). Results were affected by high heterogeneity and potential publication bias.

CONCLUSIONS

Despite these limitations and the lack of randomized trials, this meta-analysis suggests that endovascular TAAA repair could be a safer alternative to the open approach.

Living in high-poverty areas is associated with reduced survival in patients with thoracoabdominal aortic aneurysms

OBJECTIVES

Studies have demonstrated that socioeconomic status, insurance, race, and distance impact clinical outcomes in patients with abdominal aortic aneurysms. The purpose of this study was to assess if these factors also impact clinical outcomes in patients with thoracoabdominal aortic aneurysms (TAAAs).

METHODS

We conducted a retrospective review of patients with TAAAs confirmed by computed tomography imaging between 2009 and 2019 at a single institution. Patients' zip codes were mapped to American Community Survey Data to obtain geographic poverty rates. We used the standard U.S. Census definition of high-poverty concentration as >20% of the population living at 100% of the poverty rate. Our primary outcome was overall survival, stratified by whether the patient underwent repair.

RESULTS

Of 578 patients, 575 had zip code data and were analyzed. In both the nonoperative (N = 268) and operative (N = 307) groups, there were no significant differences in age, race, comorbidities, clinical urgency, surgery utilization, or surgery modality between patients living in high-poverty areas (N = 95, 16.4%) vs not. In the nonoperative group, patients from high-poverty areas were more likely to have aneurysm due to dissection (37.5% vs 17.6%, P = .03). In multivariate analyses, patients from high-poverty zip codes had significantly worse nonoperative survival (hazard ratio [HR]: 1.9, 95% confidence interval [CI]: 1.1-3.3, P = .03). In the repair group, high poverty was also a significant predictor of reduced postoperative survival (HR: 1.65, 95% CI: 1-2.63, P = .04). Adding the Gagne Index, these differences persisted in both groups (nonoperative: HR: 1.93, 95% CI: 1.01-3.70, P = .05; operative: HR: 1.62, 95% CI: 1.03-2.56, P = .04). In Kaplan-Meier analysis, the difference in postoperative survival began approximately 1.5 years after repair. Private insurance was predictive of improved postoperative survival (HR: 0.42, 95% CI: 0.18-0.95, P = .04) but reduced nonoperative survival (HR: 2.05, 95% 1.01-4.14, P = .04). Data were insufficient to determine if race impacted survival discretely from poverty status. These results were found after adjusting for age, race, sex, maximum aortic diameter, coronary artery disease, distance from the hospital, insurance, and active smoking. Interestingly, in multivariate regression, traveling greater than 100 miles was correlated with increased surgery utilization (odds ratio: 1.58, 95% CI: 1.08-2.33, P = .02) and long-term survival (HR: 0.61, 95% CI: 0.41-0.92, P = .02).

CONCLUSIONS

Patients with TAAAs living in high-poverty areas had significantly more dissections and suffered a nearly doubled risk of mortality compared with patients living outside such areas. These data suggest that these disparities are attributed to the overall impacts of poverty and highlight the pressing need for research into TAAA disparities.

Early and midterm outcomes of fenestrated and branched endovascular aortic repair in thoracoabdominal aneurysms types I through III

BACKGROUND

Fenestrated and branched endovascular aortic repair (F/BEVAR) of thoracoabdominal aortic aneurysms (TAAAs) has shown high technical success and low early mortality rates. Aneurysm extent has been reported as a factor affecting outcomes. This study aimed to assess the early and midterm follow-up outcomes of patients managed by F/BEVAR for types I through III TAAAs.

METHODS

A single-center retrospective analysis was conducted, including data from consecutive, elective and urgent (symptomatic and ruptured cases), patients treated for types I through III TAAAs, between October 1, 2011, and October 1, 2022, using F/BEVAR. Degenerative and postdissection TAAAs were included. Patients received prophylactic cerebrospinal fluid drainage (CSFD), except those under therapeutic anticoagulation, those who were hemodynamically unstable, or those with failed CSFD application. When an initial thoracic endovascular aortic repair was performed, as part of a staged procedure, no CSFD was used. Later stages and nonstaged procedures were performed under CSFD. Thirty-day mortality and major adverse events (MAEs) were analyzed. Kaplan-Meier estimates were used for follow-up outcomes.

RESULTS

F/BEVAR for types I through III TAAAs was performed in 209 patients (56.9% males; mean age, 69.6 ± 3.2 years; mean aneurysm diameter, 65.2 ± 6.2 mm); 29.2% type I, 57.9% type II, and 12.9% type III. Urgent repair was performed in 26.7% of patients (56 cases; 23 ruptured and 33 symptomatic cases) and 153 were treated electively. Thirty-two patients (15.3%) were classified as American Society of Anesthesiologists (ASA) class IV. CSFD was used in 91% and staged thoracic endovascular aortic repair was performed in 51.2% of patients. Technical success was 93.8% (96.7% in elective vs 94.6% in urgent cases; P = .92). Thirty-day mortality was 11.0% (4.6% in elective vs 28.5% in urgent cases; P < .001) and MAEs were recorded in 17.2% of cases (7.8% in elective vs 42.8% in urgent cases; P < .001). Spinal cord ischemia rate was 20.5% (17.6% in elective vs 28.7% in urgent cases; P = .08), whereas 2.9% of patients presented paraplegia (1.3% in elective and 7.1% in urgent cases; P = .03). The mean follow-up was 16 ± 5 months. Survival was 75.0% (standard error, 4.0%) and freedom from reintervention was 73.3% (standard error, 4.4%) at 36 months. ASA IV and urgent repair were detected as independent factors related to early mortality and MAE, whereas ruptured aneurysm status was related to spinal cord ischemia evolution.

CONCLUSIONS

Endovascular repair for types I through III TAAAs provides encouraging early outcomes in terms of mortality, MAE, and paraplegia, especially in an elective setting. Setting of repair and baseline ASA score should be taken into consideration during decision-making.

How We Would Treat Our Own Thoracoabdominal Aortic Aneurysm

This manuscript is intended to provide a comprehensive review of the current state of knowledge on endovascular repair of thoracoabdominal aortic aneurysms (TAAAs). The management of these complex aneurysms requires an interdisciplinary and patient-specific approach in high-volume centers. An index case is used to discuss the diagnosis and treatment of a patient undergoing fenestrated-branched endovascular aneurysm repair for a TAAA.

Comparison of efficiency and safety of open surgery, hybrid surgery and endovascular repair for the treatment of thoracoabdominal aneurysms: a systemic review and network meta-analysis

Objective

The objective of this study was to perform a network meta-analysis (NMA) to assess the efficacy and safety of three different surgical interventions- open surgical repair (OSR), hybrid surgical repair (HSR), and endovascular repair (EVAR)- for the treatment of thoracoabdominal aortic aneurysms (TAAAs).

Methods

Electronic repositories like PubMed, Embase, Web of Science, Scopus, ScienceDirect, the Cochrane library, Clinical trial, and China National Knowledge Infrastructure (CNKI) were systematically searched to identify studies that compared the efficacy of OSR, HSR, and EVAR with endografts for the treatment of TAAAs until December 24th, 2022. Random-effects and fixed-effects models were employed to analyze the data gathered in a network meta-analysis. The study's primary outcomes of interest encompassed in-hospital mortality, long-term survival rate, and postoperative complications.

Results

Eleven comparative studies meet inclusion criterias. There were 2,222 patients in OSR, 1,574 patients in EVAR and 537 patients in HSR. EVAR has lower one-month mortality than OSR (RR: 0.31; 95% CI: 0.17-0.70) and HSR (RR: 0.37; 95% CI: 0.22-0.71), and lower incident rate of renal complications than HSR (RR: 0.20; 95% CI: 0.08-0.43) and OSR (RR: 0.34; 95% CI: 0.16-0.65). Nonetheless, there was no noteworthy discrepancy identified in the long-term survival rates of these procedures.

Conclusions

As compared with OSR, HSR, and EVAR, EVER has lower one-month mortality, and lower incident rates of complications.

Systematic review registration

PROSPERO (CRD42022313829).

2022 ACC/AHA guideline for the diagnosis and management of aortic disease: A report of the American Heart Association/American College of Cardiology Joint Committee on Clinical Practice Guidelines

AIM

The "2022 ACC/AHA Guideline for the Diagnosis and Management of Aortic Disease" provides recommendations to guide clinicians in the diagnosis, genetic evaluation and family screening, medical therapy, endovascular and surgical treatment, and long-term surveillance of patients with aortic disease across its multiple clinical presentation subsets (ie, asymptomatic, stable symptomatic, and acute aortic syndromes).

METHODS

A comprehensive literature search was conducted from January 2021 to April 2021, encompassing studies, reviews, and other evidence conducted on human subjects that were published in English from PubMed, EMBASE, the Cochrane Library, CINHL Complete, and other selected databases relevant to this guideline. Additional relevant studies, published through June 2022 during the guideline writing process, were also considered by the writing committee, where appropriate.

STRUCTURE

Recommendations from previously published AHA/ACC guidelines on thoracic aortic disease, peripheral artery disease, and bicuspid aortic valve disease have been updated with new evidence to guide clinicians. In addition, new recommendations addressing comprehensive care for patients with aortic disease have been developed. There is added emphasis on the role of shared decision making, especially in the management of patients with aortic disease both before and during pregnancy. The is also an increased emphasis on the importance of institutional interventional volume and multidisciplinary aortic team expertise in the care of patients with aortic disease.

Update of T-branch use from the US Aortic Research Consortium

Aortic endograft evolution has altered our approach to treating patients with both standard and complex aortic disease. In particular, fenestrated and branched aortic endografts have allowed for the expansion of therapy to include those patients with extensive thoracoabdominal aortic aneurysms (TAAAs). The fenestrations and branches allow for the aortic endografts to achieve a seal in the proximal and distal aspects of the aorto-iliac tree, to exclude the aneurysm, while maintaining perfusion to the renal and visceral vessels. Historically, many of the grafts used for this purpose are custom made devices designed for a specific patient based on their preoperative computed tomography imaging. One downside to this approach is the time it takes to construct these grafts. Given this, much effort has been directed towards developing "off-the-shelf" grafts which may be applicable to many patients in an immediate-need bases. The Zenith T-Branch device offers an off-the-shelf graft with four directional branches. Its utilization is not applicable to all patients, but can be applied to many patients with TAAAs. Large reported series on outcomes for these devices is limited to centers in Europe as well as within the United States Aortic Research Consortium. While early outcomes appear excellent, long-term outcomes related to aneurysm exclusion, branch patency, and freedom from reintervention are needed and will be forthcoming.

In-hospital cost-effectiveness analysis of open versus staged fenestrated/branched endovascular elective repair of thoracoabdominal aneurysms

OBJECTIVE

To compare costs and effectiveness of elective open (OR) versus fenestrated/branched endovascular (ER) repair of thoracoabdominal aneurysms (TAAA) in a high-volume center.

METHODS

This single-center retrospective observational study (PRO-ENDO TAAA Study, NCT05266781) was designed as part of a larger Health Technology Assessment analysis. All electively treated TAAAs between 2013 and 2021 were analyzed and propensity-matched. Endpoints were clinical success, major adverse events (MAE), hospital direct costs, and freedom from all causes and aneurysm-related mortality and reinterventions. Risk factors and outcomes were homogeneously classified according to the Society of Vascular Surgery reporting standards. Cost-effectiveness value (CEV) and Incremental Cost-Effectiveness Ratio (ICER) were calculated, considering the absence of MAEs as a measure of effectiveness.

RESULTS

Propensity matching identified 102 pairs of patients out of 789 TAAAs. Mortality, MAE, permanent spinal cord ischemia rates, respiratory complications, cardiac complications, and renal injury were higher for OR (13% vs 5%, p=.048; 60% vs 17%, p<.001; 10% vs 3%, p=.045; 91% vs 18%, p<.001; 16% vs 6%, p=.024; 27% vs 6%, p<.001; respectively). Access complication rate (6% vs 27%; p<.001) was higher in the ER group. Intensive Care Unit stay was longer (p<.001) for OR and ER patients were discharged home more frequently (3% vs 94%; p<.001). No differences in mid-term endpoints were observed at 2 years. Despite ER reducing all the hospital cost items (-42% to -88%, p<.001), the higher expenses (p<.001) of the endovascular devices increased the overall cost of ER by 80%. CEV for ER was favorable to OR (56 365 vs 64 903 €/patient) with an ICER of 48 409 € per MAE saved.

CONCLUSIONS

ER of TAAA reduces perioperative mortality and morbidity compared to OR, with no differences in reinterventions and survival rates at midterm follow-up. Despite the expenses for endovascular grafts, ER resulted more cost-effective in preventing MAEs.

Thoracoabdominal aortic aneurysm life-altering events following endovascular aortic repair in the Vascular Quality Initiative

OBJECTIVE

Endovascular aortic aneurysm repair has lower rates of postoperative mortality and morbidity when compared with open repair. However, endovascular repair still carries the risk of postoperative dialysis, paralysis, and stroke. This study examined the rates of postoperative mortality and morbidity stratified by type of endovascular aortic aneurysm repair.

METHODS

All patients who underwent endovascular aortic aneurysm repair in the Vascular Quality Initiative registry from January 2011 - May 2022 were identified. Patients were stratified by repair type: infrarenal endovascular aortic repair (EVAR), complex EVAR, thoracic endovascular aortic repair (TEVAR), extent I-III thoracoabdominal aortic aneurysm (TAAA) repair, or aortic arch repair. The primary outcome was postoperative thoracoabdominal aortic aneurysm life-altering events (TALE) across the different treatment groups. TALE was defined as a composite outcome of postoperative mortality, dialysis, paralysis, and/or stroke. Mixed effect logistic regression modeling was used to identify procedural and anatomic factors that were independently associated with TALE.

RESULTS

A total of 52,592 EVARs, 3,768 complex EVARs, 3,899 TEVARs, 1,139 extent I-III TAAA repairs, and 479 arch repairs were identified. TALE was observed in 1.2% of EVARs, 4.8% of complex EVARs, 6.0% of TEVARs, 10% of extent I-III TAAA repairs, and 14% of arch repairs. More proximal landing zone was associated with higher odds of TALE after complex EVAR (OR 1.9 [1.2-3.1]; p=.008), TEVAR (OR 2.2 [1.4-3.5]; p=.001), and extent I-III TAAA repair (OR 2.7 [1.5-4.9]; p=.001). Aortic diameter >65mm was associated with higher odds of TALE after infrarenal EVAR (OR 1.8 [1.4-2.3]; p<.001), complex EVAR (OR 1.6 [1.1-2.3]; p=.010), TEVAR (OR 2.7 [2.0-3.8]; p<.001), and arch repair (OR 2.4; [1.3-4.4]; p=.007). The use of parallel grafting technique (chimney/snorkel/periscope) during extent I-III TAAA repair was also associated with higher odds of TALE (OR 1.8 [1.1-3.2]; p=.032). Preoperative chronic kidney disease was also associated with higher odd of TALE after infrarenal EVAR (OR 4.3 [3.0-5.7]; p<.001), complex EVAR (OR 5.2 [3.3-8.2]; p<.001), TEVAR (OR 4.5 [2.8-7.1]; p<.001), and extent I-III TAAA repair (OR 3.2 [1.6-6.7]; p=.001).

CONCLUSION

While TALE was originally described for thoracoabdominal aortic aneurysm repairs, TALE may occur after complex EVAR, TEVAR, and arch repairs as well. Therefore, TALE and its component parts should be used to evaluate the efficacy of all aortic repairs and for preoperative counseling. Additionally, surgeons should be aware of anatomic and procedural characteristics that are associated with higher odds of TALE. The anticipated need for such interventions during aortic repair should be factored into preoperative risk assessment of patients.

2022 ACC/AHA Guideline for the Diagnosis and Management of Aortic Disease: A Report of the American Heart Association/American College of Cardiology Joint Committee on Clinical Practice Guidelines

AIM

The "2022 ACC/AHA Guideline for the Diagnosis and Management of Aortic Disease" provides recommendations to guide clinicians in the diagnosis, genetic evaluation and family screening, medical therapy, endovascular and surgical treatment, and long-term surveillance of patients with aortic disease across its multiple clinical presentation subsets (ie, asymptomatic, stable symptomatic, and acute aortic syndromes).

METHODS

A comprehensive literature search was conducted from January 2021 to April 2021, encompassing studies, reviews, and other evidence conducted on human subjects that were published in English from PubMed, EMBASE, the Cochrane Library, CINHL Complete, and other selected databases relevant to this guideline. Additional relevant studies, published through June 2022 during the guideline writing process, were also considered by the writing committee, where appropriate. Structure: Recommendations from previously published AHA/ACC guidelines on thoracic aortic disease, peripheral artery disease, and bicuspid aortic valve disease have been updated with new evidence to guide clinicians. In addition, new recommendations addressing comprehensive care for patients with aortic disease have been developed. There is added emphasis on the role of shared decision making, especially in the management of patients with aortic disease both before and during pregnancy. The is also an increased emphasis on the importance of institutional interventional volume and multidisciplinary aortic team expertise in the care of patients with aortic disease.

2022 ACC/AHA Guideline for the Diagnosis and Management of Aortic Disease: A Report of the American Heart Association/American College of Cardiology Joint Committee on Clinical Practice Guidelines

AIM

The "2022 ACC/AHA Guideline for the Diagnosis and Management of Aortic Disease" provides recommendations to guide clinicians in the diagnosis, genetic evaluation and family screening, medical therapy, endovascular and surgical treatment, and long-term surveillance of patients with aortic disease across its multiple clinical presentation subsets (ie, asymptomatic, stable symptomatic, and acute aortic syndromes).

METHODS

A comprehensive literature search was conducted from January 2021 to April 2021, encompassing studies, reviews, and other evidence conducted on human subjects that were published in English from PubMed, EMBASE, the Cochrane Library, CINHL Complete, and other selected databases relevant to this guideline. Additional relevant studies, published through June 2022 during the guideline writing process, were also considered by the writing committee, where appropriate.

STRUCTURE

Recommendations from previously published AHA/ACC guidelines on thoracic aortic disease, peripheral artery disease, and bicuspid aortic valve disease have been updated with new evidence to guide clinicians. In addition, new recommendations addressing comprehensive care for patients with aortic disease have been developed. There is added emphasis on the role of shared decision making, especially in the management of patients with aortic disease both before and during pregnancy. The is also an increased emphasis on the importance of institutional interventional volume and multidisciplinary aortic team expertise in the care of patients with aortic disease.

Effectiveness of endovascular repair versus open surgery for the treatment of thoracoabdominal aneurysm: A systematic review and meta analysis

Background

Thoracoabdominal aortic aneurysms (TAAAs) are associated with significant comorbidities. The aim of our study is to compare the outcomes of open repair versus endovascular repair of TAAAs.

Methods

A thorough literature search was conducted on MEDLINE, Embase, and Cochrane Central databases. The analysis included observational studies comparing the outcomes of surgical vs endovascular aneurysm repair (EVAR) of TAAA. Mortality, spinal cord ischemia (SCI), renal failure, stroke, paraplegia, and respiratory and cardiac problems were all included in the studies. The results were provided as relative risks (RRs) with 95% confidence intervals (CIs). These were then aggregated using an inverse variance weighted random-effects model, and the pooled analysis was displayed using forest plots.

Results

This meta-analysis compromising of twelve studies revealed significant results, favoring endovascular repair versus open surgery for all-cause mortality (HR = 1.91; 95% CI: 1.68–2.18; P < 0.00001), SCI (HR = 1.62; 95% CI: 1.18–2.21; P = 0.003), respiratory complications (HR = 2.22; 95% CI: 1.78–2.77; P < 0.00001), and cardiac complications (HR = 1.66; 95% CI: 1.38–2.00; P < 0.00001). Upon subgroup analysis based on propensity matched, results were consistent and significant for the outcomes of all-cause mortality, cardiac complications, and respiratory complications. For the propensity unmatched subgroup, the incidence of all-cause mortality, SCI, respiratory complications, and cardiac complications were lower among endovascular repair cohort.

Conclusion

Current evidence supports the use of endovascular repair over open surgery. However, there is a need to conduct dedicated randomized controlled trials to effectively compare and determine the benefits and risk of both strategies.

•

Current findings support endovascular repair over open surgery for the treatment of thoracoabdominal aneurysms (TAAA).

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Endovascular repair for TAAA can help reduce the risk of all-cause mortality, respiratory and cardiac complications.

•

Consistent results were noted upon subgroup analyses.

•

Dedicated randomized controlled trials are warranted to compare the benefits and risk of both strategies.

Single-Center Experience with the Femoral-to-Brachial Preloaded Delivery System for Fenestrated-Branched Endovascular Repair of Complex Aortic Aneurysms

PURPOSE

To assess technical aspects and outcomes of fenestrated-branched endovascular aortic repair (FB-EVAR) using a femoral-to-brachial (FTB) preloaded delivery system (PDS) with two separate configurations.

METHODS

Clinical data of all consecutive patients enrolled in a prospective study to evaluate FB-EVAR for complex abdominal and thoracoabdominal aortic aneurysms (CAAAs & TAAA) between 2013 and 2020 were reviewed. Patients treated with FTB-PDS were included. The two configurations included 4 trans-brachial preloaded wires (4BR) or 2 trans-brachial and 2 transfemoral preloaded wires (2BR-2FE). Outcome measures included technical success, procedural metrics, 30-day or in-hospital mortality, major adverse events (MAEs), and target-vessel outcomes.

RESULTS

There were 115 patients with a mean age of 73.8 ± 8 years, treated with FTB-PDS. Of these, 62 patients (54%) had 4BR and 53 patients (46%) had 2BR-2FE FTB-PDS. There were 106 TAAA (92%) and 9 CAAAs (8%). Technical success, defined as successful implantation of the stent-graft and all intended target-vessel stents without type I or III endoleak, was 97%, with no differences in total operating time, endovascular time, and radiation dose between groups. There were 3 deaths (3%) at 30 days. MAEs were noticed in 21 patients (18%) with no difference between groups, including new-onset dialysis (2% vs. 4%, P = 0.59), and paraplegia (7% vs. 11%, P = 0.51), for 4BR and 2BR-2FE, respectively. Patient survival and freedom from aortic-related mortality at 2-years were 79 ± 5% and 97 ± 1.7%, respectively, with no difference between groups.

CONCLUSION

The use of FTB-PDS for FB-EVAR is safe with high technical success and a reasonable rate of MAEs. Each configuration provides specific benefits based on patient anatomy, while having similar procedural metrics and clinical outcomes.

Thoracoabdominal Aortic Disease and Repair: JACC Focus Seminar, Part 3

Thoracoabdominal aortic disease is a rare but life-threatening condition that requires expert multidisciplinary collaborative management. Intervention is indicated in patients with symptomatic aneurysms or when an aneurysm reaches a certain threshold of diameter or rate of expansion. The strategies for spinal cord and end-organ protection have evolved over several decades, resulting in improved outcomes after repair. Open repair, although invasive, provides definitive and durable repair. Endovascular approaches are rapidly evolving, and the results with fenestrated and branched endografts are promising. Both open repair and endovascular repair require highly specialized expertise, and outcomes are best when repair is undertaken in an elective setting by a dedicated team. Patients with degenerative thoracoabdominal aortic aneurysms and chronic dissections should be followed up closely and referred for elective repair when indicated.

Fenestrierte und verzweigte endovaskuläre Aortenprothesen

Hintergrund

Komplexe abdominelle aortale Pathologien, welche die Abgänge der Viszeralarterien miterfassen und bei denen kein adäquater proximaler Hals gegeben ist, können heute mittels fortgeschrittener FEVAR/BEVAR-Technik („fenestrated/branched endovascular aneurysm repair“) mit ähnlicher Sicherheit und vergleichbaren Erfolgsraten behandelt werden wie infrarenale Pathologien mit konventionellem EVAR.

Methodische Innovationen und Probleme

Zur Versorgung der Viszeralarterien können Fenestrierungen (bei Abgang der Viszeralarterie aus der nichtdilatierten Aorta) oder Verzweigungen (bei Abgang aus der dilatierten Aorta) verwendet werden. Beide Arten von Öffnungen werden mit Verbindungsstentgrafts (VSG) zu den Viszeralarterien abgedichtet. Mehrere Hersteller bieten fenestrierte oder verzweigte Endoprothesen an, wobei diese nur in Einzelfällen CE-zertifiziert und überwiegend in Europa als individuelle Sonderanfertigungen patientenbezogen erhältlich sind. Dies setzt eine entsprechende Lieferzeit voraus, was die Behandlung akuter Patienten mit solchen Prothesen unmöglich macht. Es liegen allerdings zwei Produkte von vierfach verzweigten Endoprothesen vor, die einen größeren Bereich der anatomischen Gegebenheiten bei thorakoabdominellen Aneurysmen auch im Akutfall abdecken und behandelbar machen. Sämtliche FEVAR- und BEVAR-Hauptkörper benötigen VSG, die durchgehend von Fremdherstellern stammen und von denen gegenwärtig noch kein einziges Produkt für diese Anwendung zertifiziert ist.

Empfehlungen

Da Probleme an Verbindungsstentgrafts eine wesentliche Ursache für Reinterventionen sind, sollte in der Nachsorge Knickbildungen und Brüchen an diesen Verbindungsstents besonderes Augenmerk geschenkt und von der Verwendung einschichtiger Designs beim BEVAR abgesehen werden.

Comparative Early Results of In-Situ Fenestrated Endovascular Aortic Repair and Other Emergent Complex Endovascular Aortic Repair Techniques for Ruptured Suprarenal and Thoracoabdominal Aortic Aneurysms at a Regional Aortic Center

INTRODUCTION

Emergent endovascular repair of suprarenal (SRAAA) and thoracoabdominal aortic aneurysms (TAAA) poses a significant challenge due to the need for branch vessel incorporation, time constraints, and lack of dedicated devices. Techniques to incorporate branch vessels have included parallel grafting (PG), physician modified endografts (PMEG), double-barrel/reversed iliac branch device (DB/rIBE), and in situ fenestration (ISF). This study describes a single-center experience and the associated outcomes when using these techniques for ruptured SRAAA and TAAA.

METHODS

A retrospective review of patients who underwent endovascular repair of ruptured SRAAA and TAAAs from July 2014 - March 2021 with branch vessel incorporation was performed. Clinical presentation, intraoperative details, and postoperative outcomes of those who underwent ISF were compared to those who underwent repair using non-ISF techniques. The primary outcome of interest was in-hospital mortality. Secondary outcomes were major adverse events including myocardial infarction, respiratory failure, renal dysfunction, new onset dialysis, bowel ischemia, stroke, and spinal cord ischemia.

RESULTS

Forty-two patients underwent endovascular repair for ruptured SRAAA and TAAA, 18 of whom underwent ISF repair. Seventy-two percent of ISF patients were hypotensive prior to surgery, compared to 46% of the patients who underwent repair using non-ISF techniques (PMEG, PG, or DB/rIBE). The total procedural and fluoroscopy times were similar between the two groups despite a greater mean number of branch vessels incorporated with the ISF technique (3.1 vs. 2.2 per patient, P = .015). In-hospital mortality was 19% for all ruptures, and 25% for ruptures with hypotension. Compared to the non-ISF group, in-hospital mortality trended lower in the ISF group (11% vs. 25%, P = .233), reaching statistical significance when comparing patients who presented with hypotension (8% vs 45%, P =.048). The rate of major adverse events was 57% across all techniques and did not significantly differ between the ISF and non-ISF groups, with postoperative renal dysfunction being the most frequent complication (48%). Overall, ISF became the most commonly utilized technqiue later in the study period.

CONCLUSIONS

While emergent endovascular repair of ruptured SRAAA/TAAA remains a challenge, a number of techniques are available for expeditious treatment. In this series, ISF was associated improve survival, including a 5-fold reduction in mortality in patients presenting with hypotension, and has now become the dominant technique at our center. Despite these advantages, postoperative complications and reinterventions are common. Further experience and longer-term follow-up is needed to validate these initial results and assess durability.

Endovascular versus conventional open surgical repair for thoracoabdominal aortic aneurysms

BACKGROUND

Thoracoabdominal aortic aneurysms (TAAAs) are a life-threatening condition which remain difficult to treat. Endovascular and open surgical repair (OSR) provide treatment options for patients, however, due to the lack of clinical trials comparing these, the optimum treatment option is unknown.

OBJECTIVES

To assess the effectiveness and safety of endovascular repair versus conventional OSR for the treatment of TAAAs.

SEARCH METHODS

The Cochrane Vascular Information Specialist searched the Cochrane Vascular Specialised Register, CENTRAL, MEDLINE, Embase, CINAHL and AMED databases and World Health Organization International Clinical Trials Registry Platform and ClinicalTrials.gov trials registers to 26 April 2021. We also searched references of relevant articles retrieved from the electronic search for additional citations.

SELECTION CRITERIA

We considered all published and unpublished randomised controlled trials (RCTs) and controlled clinical trials (CCTs) comparing endovascular repair to OSR for TAAAs for inclusion in the review. The main outcomes of interest were prevention of aneurysm rupture (participants without aneurysm rupture up to 5 years from intervention), aneurysm-related mortality (30 days and 12 months), all-cause mortality, spinal cord ischaemia (paraplegia, paraparesis), visceral arterial branch compromise causing mesenteric ischaemia or renal failure, and rate of reintervention.

DATA COLLECTION AND ANALYSIS

Two review authors independently screened all titles and abstracts identified from the searches to identify those that met the inclusion criteria. We planned to undertake data collection, risk of bias assessment, and analysis in accordance with Cochrane recommendations. We planned to assess the certainty of the evidence using GRADE.

MAIN RESULTS

No RCTs or CCTs met the inclusion criteria for this review.

AUTHORS' CONCLUSIONS

Due to the lack of RCTs or CCTs, we were unable to determine the safety and effectiveness of endovascular compared to OSR in patients with TAAAs and are unable to provide any evidence on the optimal surgical intervention for this cohort of patients. High-quality RCTs or CCTs addressing this objective are necessary, however conducting such studies will be logistically and ethically challenging for this life-threatening disease.

Physician-modified endografts are associated with a survival benefit over parallel grafting in thoracoabdominal aneurysms

OBJECTIVE

Physician-modified endografts (PMEG) and parallel grafting (PG) are important techniques for endovascular repair of complex aortic aneurysms using off-the-shelf devices. However, there is little data regarding the relative efficacy and outcomes of these techniques in thoracoabdominal extent aneurysms. This study sought to compare outcomes of PG and PMEG across different extents of thoracoabdominal aneurysms to which they can be employed.

METHODS

The SVS VQI TEVAR/Complex EVAR module was queried for all patients undergoing repair of an unruptured, thoracoabdominal aneurysm (TAAA, Extents I-IV) years 2012-2020; aneurysm types were defined by repair extent as determined by proximal and distal seal zones. Patients were differentiated based on whether they received repair with a physician-modified endograft (PMEG) or parallel grafting technique (PG). The primary outcomes for this study were overall survival and freedom from aneurysm/procedure-related mortality at 1-year determined via Kaplan-Meier analysis, with Cox hazard regression analysis conducted to examine the independent association of repair modality with primary outcomes.

RESULTS

813 patients met inclusion criteria (TAAA I-III 362, TAAA IV 451; 426 PG, 387 PMEG). PMEG repairs were performed at centers with a nearly 2-3-fold higher annual volume of endovascular TAAA repairs. Type Ia endoleaks were reduced with PMEG repair, most significantly in TAAA IV (TAAA I-III: 2.2% PMEG vs. 10% PG, p = 0.2; TAAA IV: 1.2% PMEG vs. 21.6% PG, p <0.001). Thoracoabdominal repairs demonstrated improved survival at 1-year with PMEG devices, significant for TAAA I-III repairs (TAAA I-III: PMEG 85% vs. PG 74%, p = 0.01; TAAA IV: 84% PMEG vs. PG 78%, p = 0.08). Freedom from aneurysm/procedure-related mortality was also improved with PMEG repairs, remaining significant at 1-year in the case of TAAA IV (TAAA I-III: PMEG 94% vs. PG 86%, p = 0.06; TAAA IV: PMEG 94% vs. PG 88%, p = 0.02). PMEG demonstrated reductions in several measures of post-operative morbidity, including stroke/death, MACE, and post-operative complications. In multivariate analysis, repair modality was not associated with either primary outcome, rather, several perioperative complications conveyed the greatest hazard for both primary outcomes across repair extents.

CONCLUSIONS

Survival after endovascular TAAA repair is improved with the use of PMEG compared to PG. Several key factors of this study demonstrate the shortcomings of parallel grafting in complex aneurysm repair, namely high rates of critical endoleaks, the need for adjunctive access sites, and an increase in perioperative complications that influence longer-term outcomes.

Endovascular repair for thoracoabdominal aortic aneurysms: current status and future challenges

Open surgical repair has been the gold standard for treatment of thoracoabdominal aortic aneurysms (TAAA). Currently, open surgical repair has been reserved mostly for young and fit patients with connective tissue disorders, using separate branch vessel reconstructions instead of 'island' patches, and distal perfusion instead of a 'clamp and go' technique. Endovascular repair has gained widespread acceptance because of its potential to significantly decrease morbidity and mortality. Several large aortic centers have developed dedicated clinical programs to advance techniques of fenestrated-branched endovascular aortic repair (FB-EVAR) using patient-specific and off-the-shelf devices, which offers a less-invasive alternative to open repair. Although FB-EVAR was initially considered an option for older and frail patients, many centers have expanded its indications to any patient with suitable anatomy and no evidence of connective tissue disorders, independent of their clinical risk. In this article, we review current techniques and outcomes of endovascular TAAA repair.

Anesthetic Considerations in Endovascular Repair of the Ascending Aorta

Since the first endovascular aortic repair in 1990, endovascular devices and the indications for their use have significantly grown. Considerable progress has been made in endovascular devices and techniques, such that endovascular repair is now considered first-line treatment for patients with descending aortic disease. However, for patients with ascending aortic disease, open surgical repair with cardiopulmonary bypass and hypothermic cardiac arrest was the only option until recently. Although the outcomes for open surgical repair of the ascending aorta have improved over the years, approximately 30% of patients with an emergent surgical indication, such as type A aortic dissection, are considered to be too high risk for open repair. For these patients, endovascular repair of the ascending aorta offers a life-saving procedure. The ascending aorta is regarded as the final frontier for endovascular therapy. Endovascular repair of it has posed a formidable challenge thus far, due to its unique anatomy, hemodynamic forces, and lack of an appropriate stent-graft designed specifically for the ascending aorta. Although currently there are no comprehensive data from randomized clinical trials, there are several case series and case reports that have shown favorable outcomes. Improvements in available devices soon will drive an exponential increase in the number of patients undergoing endovascular ascending aortic repair. In this review, the authors discuss multiple aspects of endovascular ascending aortic repair including the unique surgical and anesthetic considerations, the devices used, and the available outcomes data, and future directions are also explored.

Long-term survival after descending thoracic and thoracoabdominal aortic aneurysm repair

OBJECTIVE

Patients with descending thoracic aortic aneurysms (dTAA) or thoracoabdominal aortic aneurysms (TAAA) often have a variety of medical comorbidities. Those that are deemed acceptable for intervention undergo complicated repairs with good early outcomes. The purpose of this study was to identify variables that were associated with mortality over time.

METHODS

This was a retrospective review of a prospectively maintained database at our institution from 1983 to 2015. Patients were included if they underwent open or endovascular repair for dTAA or TAAA. Patients were excluded if they were intervened on for traumatic transections. The primary outcome for the study was long-term survival. Secondary outcomes included aortic-related mortality. We had mortality and survival data on all patients.

RESULTS

A total of 946 patients met our study criteria with a median follow-up of 102.8 months (interquartile range [IQR], 58.9-148.2 months). The median age of the cohort was 71 years (IQR, 63-77 years) with the majority of patients being male (58.1%). The extent of TAAA pathology was as follows: type I (14.2%), type II (21.2%), type III (17.1%), type IV (26.2%), and dTAA (21.2%). A total of 147 patients (15.5%) had a prior dissection. The median diameter of aneurysm was 6.4 cm (IQR, 6.0-7.0 cm). A total of 158 patients (16.7%) underwent endovascular repair over the study period. Variables associated with mortality over time were age, surgical era, acute pathology, dissection, preoperative creatinine, and type IV TAAAs. In addition, experiencing the following complications in the postoperative period was associated with mortality over time: neurological, cardiac, and pulmonary. Aortic-related mortality was 2.1% (n = 20) over the study period. Patients who underwent endovascular repair for acute conditions had better long-term survival when compared with open repair. However, there were no differences in long-term survival between open and endovascular repair for nonacute cases. In addition, repair in the more modern era was associated with improved survival.

CONCLUSIONS

TAAAs can be repaired with reasonable perioperative mortality rates. Once patients undergo repair of their aneurysm, aortic-related mortality remains low. The addition of endovascular options has dramatically changed management of patients with dTAA and TAAA. Further, endovascular repair was associated with decreased perioperative mortality and significantly increased long-term survival in acute patients. Patients undergoing TAAA repair are generally considered high risk and therefore require extensive long-term follow-up for management of their comorbidities and complications, because these are the main contributors to mortality over time.

Health care costs of endovascular compared with open thoracoabdominal aortic aneurysm repair

OBJECTIVE

To compare 1-year health care costs between endovascular and open thoracoabdominal aortic aneurysm (TAAA).

METHODS

Population-based administrative health databases were used to capture TAAA repairs performed in Ontario, Canada, between January 2006 and February 2017. All health care costs incurred by the Ministry of Health from a single-payer universal health care system were included. Costs of the aortic endografts and ancillary devices for the index procedure were estimated as C$44,000 per endovascular case vs C$1000 for open cases, based on previous reports. Costs (2017 Canadian dollars) were calculated in phases (1, 1-3, 3-6, and 6-12 months from surgery) with censoring for death. For each phase, propensity score matching of endovascular and open cases based on preoperative patient and hospital characteristics was used. The association between preoperative characteristics (including repair approach) and the first month postprocedure cost was characterized through multivariable analysis.

RESULTS

Overall 664 TAAA repairs were identified (open, n = 361 [54.5%] and endovascular, n = 303 [45.6%]). At 1 month, the median cost was higher for endovascular TAAA repair in the prematching cohort (C$64,892 vs C$36,647; P < .01). Similarly, in 241 well-balanced endovascular/open patient pairs after propensity score matching, the median health care costs were higher in endovascular TAAA cases during the first month (C$62,802 vs C$33,605; P < .01). The 1- to 3-month median cost was not statistically different between endovascular and open TAAA cases either before matching (C$2781 vs C$2618; P = .71) or after matching (C$2762 vs C$2092; P = .58). Likewise, in the 3- to 6-month and 6- to 12-month postprocedure intervals, there were no significant differences in the median health care costs between groups. On multivariable analysis, older age (5-year increments) (relative change [RC] in mean cost, 1.05; 95% confidence interval [CI], 1.04-1.06; P = .01), urgent procedures (RC, 1.29; 95% CI, 1.10-1.52; P < .01), and history of stroke (RC, 1.34; 95% CI, 1.00-1.78; P = .05) were associated with higher costs in the first postoperative month, whereas open relative to endovascular TAAA repair was associated with a decreased 1-month cost (RC, 0.65; 95% CI, 0.56-0.74; P < .01).

CONCLUSIONS

TAAA repair is expensive regardless of technique. Compared with open TAAA repair, endovascular repair was associated with a higher early cost, owing to the upfront cost of the endograft and aortic ancillary devices. There was no difference in cost from 1 to 12 months after repair. A decrease in the cost of endovascular devices might allow equivalent costs between endovascular and open TAAA repair.

Increasing Role of Fenestrated and Branched Endoluminal Techniques in the Thoracoabdominal Segment Including Supra- and Pararenal AAA

Fenestrated and branched stent-grafts are being increasingly used to address complex pararenal and thoracoabdominal aortic aneurysms by endovascular means. The present paper describes the current indications, anatomical suitability and techniques of fenestrated and branched stent-grafts in the treatment for pararenal and thoracoabdominal aortic pathologies. Published outcomes with regard to perioperative mortality and morbidity, survival, reinterventions and target vessel patency during follow-up are also presented. Finally, advantages and disadvantages of endovascular repair as compared to open repair are discussed.

A scoping review of the rationale and evidence for cost-effectiveness analysis of fenestrated-branched endovascular repair for intact complex aortic aneurysms

BACKGROUND

Cost-effectiveness analysis of new interventions is increasingly required by policymakers. For intact complex aortic aneurysms (CAAs), fenestrated-branched endovascular aneurysm repair (F/B-EVAR) offers a minimally invasive alternative option for patients who are physically ineligible for open surgical repair (OSR). Thus, F/B-EVAR is increasingly used, but whether it represents a cost-effective treatment option remains unknown.

METHODS

A scoping review of the literature was conducted from the PubMed, Ovid Embase, and Scopus databases. They were searched to identify relevant English-language articles published from inception to December 31, 2019. All costs in the identified literature were transformed to U.S. dollar values by the following exchange rate: 1 GBP = 1.3 USD; 1 EUR = 1.1 USD.

RESULTS

At this literature search, no randomized clinical trials assessing cost-effectiveness of F/B-EVAR vs OSR for intact CAAs were found. Also, no health economic evaluation studies were found regarding use of F/B-EVAR in patients unfit for OSR. A Markov model analysis based on seven observational center- or registry-based studies published from 2006 to 2014 found that the incremental cost-effectiveness ratio for F/B-EVAR vs OSR was $96,954/quality-adjusted life-year. In the multicenter French Medical and Economical Evaluation of Fenestrated and Branched Stent-grafts to Treat Complex Aortic Aneurysms (WINDOW) registry (2010-2012), F/B-EVAR had a higher cost than OSR for a similar clinical outcome and was therefore economically dominated. At 2 years, costs were higher with F/B-EVAR for juxtarenal/pararenal aneurysms and infradiaphragmatic thoracoabdominal aneurysms but similar for supradiaphragmatic thoracoabdominal aneurysms. The higher costs were related to a $24,278 cost difference of the initial admission (95% of the difference at 2 years) due to stent graft costs. Both these studies, however, included a highly varying center experience with complex endovascular aortic repair, and their retrospective design is subject to selection bias for chosen treatment, which could affect the studied outcome. In contrast, in a more recent U.S. database analysis (879 thoracoabdominal aortic aneurysm repairs, 45% OSRs), the unadjusted total hospitalization cost of OSR was significantly higher compared with F/B-EVAR (median, $44,355 vs $36,612; P = .004). In-hospital mortality as well as major complications were two to three times higher after OSR, indicating that endovascular repair might be the economically dominant strategy.

CONCLUSIONS

The literature regarding cost-effectiveness analysis of F/B-EVAR for intact CAAs is scarce and ambiguous. Based on the limited nonrandomized available evidence, stent grafts are the main driver for F/B-EVAR expenses, whereas cost-effectiveness in relation to OSR may vary by health care setting and selection of patients.

Successful management of aortoesophageal fistula caused by esophageal cancer using thoracic endovascular aortic repair

Aortoesophageal fistula (AEF) is a highly life-threatening condition, even when treated promptly. However, little is known about the treatment for AEF in patients with advanced esophageal cancer. We report the case of a 69-year-old man diagnosed with esophageal squamous cell carcinoma (ESCC) that was admitted to our hospital for ESCC treatment. On diagnosis of unresectable ESCC invading the thoracic aorta, chemotherapy was administered. The response to treatment after two courses was evaluated as stable disease. We performed radiation therapy followed by bypass operation for esophageal stenosis. After radiation therapy, AEF was detected. His condition improved after hemostasis using thoracic endovascular aortic repair (TEVAR). He was discharged from our care after treatment with antibiotics; he died due to cancer progression 7 months after TEVAR. AEF with ESCC is a lethal condition that may occur during cancer treatment; however, TEVAR might help improve the patient's condition.

Current Status of Endoluminal Treatment of Descending Thoracic Aortic Aneurysms

Thoracic endovascular aortic repair (TEVAR) was proved to be effective in thoracic descending aortic aneurysm (TDAA) repair in 1994 and approved by the FDA in 2005. Since then, TEVAR has become the first-line, recommended treatment for intact or ruptured DTAA or as a bridge to definitive open surgical repair in connective tissue disease. TEVAR has decreased perioperative morbidity and mortality compared to open surgery due to the lack of thoracotomy, aortic cross-clamping and left heart bypass. Improvement in materials, manufacturing and device delivery systems have allowed for the expansion of indications. Thoughtful and accurate pre-procedure planning is the hallmark of successful TEVAR. Familiarization and adherence to the instructions for use for an aortic device will give the best possible chance of success.

Postoperatively increased bioactive adrenomedullin is related to adverse outcome after complex aortic surgery

Summary: Background: Open and endovascular thoracoabdominal aortic aneurysm repair is related to major complications and increased mortality rates. Up to now, specific biomarkers for adverse outcome are scarce, although routine usage of such biomarkers could enable an earlier and more appropriate treatment of complications during the postoperative course after complex aortic aneurysm repair. Patients and methods: In a prospective single-center study including 33 patients (48.5 % women, mean age 63.0 ± 16.2 years) undergoing elective complex open and endovascular aortic aneurysm repair, bioactive adrenomedullin (bio-ADM) was measured for 72 h perioperatively and an association with clinical endpoints, namely cardiogenic shock, death and the combined endpoint of the two aforementioned parameters was assessed. Furthermore, the association between bio-ADM and baseline characteristics and perioperative details including sepsis biomarkers score were assessed. Results: 51.5 % (n = 17) of patients developed postoperative acute kidney injury, 21.2 % (n = 7) pneumonia and 18.2 % (n = 6) sepsis. Cardiogenic shock was observed in 12.1 % (n = 4) patients. The in-hospital mortality rate was 18.2 % (n = 6), and 24.2 % (n = 8) of patients developed cardiogenic shock and/or died in hospital. A significant correlation of bio-ADM concentrations from all available time points was observed with leukocytes (r = 0.37, P < 0.0001), C-reactive protein (r = 0.56, P < 0.001) and serum creatinine levels (r = 0.52, P < 0.001). Increased bio-ADM at 12 h, 24 h, 48 h and 72 h after admission to ICU was associated with both, in-hospital death and cardiogenic shock, with an area under the curve for the combined endpoint of 0.598, 0.720, 0.880 and 0.967. Bio-ADM concentrations at 48 h and 72 h after admission to ICU were predictive for in-hospital death and cardiogenic shock (both P < 0.01). Conclusions: Bio-ADM may serve as postoperative biomarker for cardiogenic shock and death after complex open and endovascular aortic aneurysm repair, potentially enabling an earlier and by that more adequate treatment of adverse outcome after major surgery.

Endovascular Treatment of Tracheoinnominate Artery Fistula: Case Report and Literature Review With Pooled Cohort Analysis

To pool data from published cases of tracheoinnominate artery fistula (TIF) treated with surgical or endovascular techniques along with reporting a case of similar presentation. A total of 261 cases in 137 published case reports and case series were identified through a comprehensive systematic literature review. Data regarding patient characteristics, treatment, and follow-up were extracted. A local case of a 14-year-old boy with TIF due to longstanding tracheostomy treated with stent-graft placement was added to the data. Comparison of the complication rates between surgical vs endovascular interventions was done with the chi-square test. Factors associated with longer survival were assessed by the Cox regression analysis. Thirty-three (12.6%) of the reported cases were treated endovascularly, 137 (52.3%) were treated surgically, and 92 (35.1%) were reported with no definitive treatment. Mean age was 34 ± 22 years, and 61% were males. The mean time interval between tracheotomy placement and bleeding was 1 ± 2.5 years. A lower procedure-related complication (30% vs 50%, P = 0.045) and 30-day mortality (9% vs 23%, P = 0.008) rates had been reported with percutaneous approaches compared to surgery. No percutaneous procedure was reported prior to year 2000. In multivariate analysis stratified by publication year, a shorter tracheostomy-to-bleeding time (year) was significantly associated with higher hazards of death (hazard ratio: 1.22, P = 0.017). Type of intervention (percutaneous vs surgery) was not associated with postintervention survival (adjusted hazard ratio: 0.78, P = 0.558). Endovascular stent grafting can have a comparable postprocedural survival and lower complication rates vs open surgical repair in treatment of TIF.

Midterm Results of Endovascular Treatment for the Patients with Thoracoabdominal Aortic Aneurysms

Treatment of thoracoabdominal aortic aneurysm (TAAA) remains a challenging pathology. Technologies and innovations of endovascular treatment, in particular the evolution of fenestrated and branched stent graft for complex aortic pathologies such as TAAA have provided excellent short-term results. However, the mid-term and long-term results of endovascular treatment for TAAA including endoleaks and branch patency are still unclear. This article provides an overview of available devices and results of endovascular treatment for TAAAs. (This is a translation of Jpn J Vasc Surg 2019; 28: 67–74.)

Three-year follow-up of composite stent grafts used in the repair of Crawford Type III thoracoabdominal aortic aneurysms; A case report

Complex aortic aneurysms are difficult to treat endovascularly and so techniques have been developed to broaden the management options. We report a case of 51-year-old man with several thoracoabdominal aortic aneurysms (TAAAs) who underwent endovascular repair with “off-label” stent grafts. Three aortic stent grafts and four branched stent grafts were used in the procedure using chimney and periscope techniques. The patient was followed for three years with regular computed tomography angiography (CTA). Scans at 3 and 12 months showed that the TAAAs were repaired and all visceral arteries were patent. Although, scans at the two- and three-year follow-ups showed that the stent graft in the superior mesenteric artery was occluded, the patient did not have any complications probably as a result of coeliac artery compensation.

A systematic review and meta-analysis of early outcomes after endovascular versus open repair of thoracoabdominal aortic aneurysms

OBJECTIVE

The objective of this study was to compare the early results of endovascular vs open thoracoabdominal aortic aneurysm (TAAA) repair.

METHODS

MEDLINE and Embase were searched for studies from January 2006 to March 2018 that compared endovascular vs open repair of TAAA using branched or fenestrated endografts. Data were subjected to a meta-analysis using a random-effects model. The outcomes of interest included early mortality, spinal cord injury, renal failure requiring dialysis, stroke, and hospital length of stay.

RESULTS

Eight comparative studies met inclusion criteria. There were two retrospective propensity-matched studies, two unadjusted single-center retrospective studies, and four unadjusted national population-based studies. Mortality in the matched studies was equivalent in both groups. Pooled analysis of all unmatched observational studies revealed a survival benefit for endovascular over open repair (relative risk [RR], 0.63; 95% confidence interval [CI],0.45-0.87); P < .01, I² = 47%). Endovascular repair was also associated with lower incidence of spinal cord injury (RR, 0.65; 95% CI, 0.42-1.01; P = .05; I² = 28%). For unmatched studies, pooled RR of renal failure requiring dialysis significantly favored endovascular repair (RR, 0.44; 95% CI, 0.23-0.85; P = .01; I² = 0%), although in the adjusted cohort, risk of dialysis was not different (RR, 1.00; 95% CI, 0.06-15.65; P = 1.00). Postoperative stroke rate was reported in three unadjusted studies and was not different between groups (RR, 0.81; 95% CI, 0.28-2.40; P = .71; I² = 77%). Hospital length of stay was reported in four studies and was shorter in the endovascular group (mean difference, -4.4 days; 95% CI, -6.6 to -1.7; P < .01; I² = 73%).

CONCLUSIONS

There are few reports comparing endovascular vs open repair of TAAAs. Short-term outcomes may be improved in patients undergoing endovascular treatment of TAAA on the basis of a limited number of studies with high risk of bias. These findings highlight the need for larger comparative studies with standardization of reporting.

Should endovascular approach be considered as the first option for thoraco-abdominal aortic aneurysms?

Open surgical repair has been the gold standard for treatment of thoracoabdominal aortic aneurysms (TAAAs). The technique of open TAAA repair has evolved from the use of "island" patch incorporation to separate branch vessel bypass, from "clamp and go" to routine use of distal perfusion, and towards more extensive repair in patients with connective tissue disorders. Open TAAA repair can be done with excellent results in highly specialized centers. However, these operations continue to carry excessive risk when performed outside large aortic centers, with 30-day mortality estimated on 20% according to statewide and national databases. In octogenarians, the mortality of elective open TAAA repair can be up to 40%. Endovascular repair was introduced as an alternative to open surgical repair in the elderly or higher risk patients using hybrid reconstruction, parallel grafts or fenestrated and branched endografts. Several large aortic centers have developed dedicated clinical programs to advance techniques of fenestrated-branched endovascular repair using patient-specific and off-the-shelf devices, offering a minimally invasive alternative to open repair allowing treatment of increasingly older and sicker TAAA patients. During the last decade, improvements in device design, patient selection, spinal cord injury protocols, and perioperative management have contributed to a continued decline in morbidity and mortality of fenestrated-branched endovascular aortic repair, challenging open surgical repair as the new "gold standard" for treatment of TAAAs. Despite the improved results, endovascular repair is a highly technical procedure that requires vast experience, involves a significant risk of complications, and also, has an impact on patients' physical quality of life. In this article, we review the current technical aspects of endovascular TAAA repair with the main focus on the evidence of open versus endovascular outcomes of TAAA repair.

Synchrotron radiation computed tomography versus conventional computed tomography for assessment of four types of stent grafts used for endovascular treatment of thoracic and abdominal aortic aneurysms

Background

To determine the accuracy of synchrotron radiation computed tomography (CT) for measurement of stent wire diameters for in vitro simulation of endovascular aneurysm repair by four different types of stent grafts when compared to conventional CT images.

Methods

This study was performed using an aorta model with implantation of four aortic stent grafts for endovascular treatment of thoracoabdominal and abdominal aortic aneurysms. The aorta model was scanned using synchrotron radiation CT with beam energies ranging from 60 to 90 keV with 10 keV increment at each scan and spatial resolution of 41.6 µm per pixel. Stent wire diameters were measured at the top and body regions of each stent graft based on 2-dimensional (2D) axial and 3-dimensional (3D) reconstruction images, with measurements compared to those obtained from 128-slice CT images which were acquired with slice thickness of 0.5 mm.

Results

Synchrotron radiation CT images clearly demonstrated stent graft details with accurate assessment of stent wire diameters, with measurements at the top of stent grafts (between 0.32±0.02 and 0.47±0.02 mm) similar to the actual diameters (between 0.32±0.01 and 0.48±0.01 mm) when the beam energies of 70 and 80 keV were used, regardless of the types of stent grafts assessed. A beam energy of 60 keV resulted in stent wires thicker than the actual sizes, although this did not reach statistical significance (P=0.07-0.29), while the beam energy of 90 keV led to stent wires smaller than the actual sizes at the top (P=0.16) and body region (P=0.02) of stent grafts on 2D axial images. The stent wire sizes measured at the body region of stent grafts on 3D synchrotron radiation images (between 0.19±0.02 and 0.43±0.02 mm) were significantly smaller than the actual diameters (P=0.02-0.04). Stent wires were overestimated on conventional CT images with diameters more than 2-fold larger than the actual sizes (P=0.007-0.03) at both top and body regions of all four stent grafts.

Conclusions

This study further confirms the accuracy of high-resolution synchrotron radiation CT in image visualization and size measurement of different aortic stent grafts with measured wire diameters similar to the actual ones, thus allowing for more accurate assessment of stent wire details for endovascular repair of aortic aneurysms.